Provider Demographics
NPI:1417096843
Name:RYAN, MITCHELL RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:RAY
Last Name:RYAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 NW 22ND AVE
Mailing Address - Street 2:DEPARTMENT OF PATHOLOGY
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3025
Mailing Address - Country:US
Mailing Address - Phone:503-413-7636
Mailing Address - Fax:503-413-6267
Practice Address - Street 1:1015 NW 22ND AVE
Practice Address - Street 2:DEPARTMENT OF PATHOLOGY
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3025
Practice Address - Country:US
Practice Address - Phone:503-413-7636
Practice Address - Fax:503-413-6267
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21690207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1344158Medicaid
WA8429037Medicaid
WAG8879570Medicare PIN
OR1344158Medicaid
ORR103734Medicare PIN
WA8429037Medicaid